hard · NCLEX-RN psychosocial
The nurse evaluates the client's progress at 18:00. Which findings indicate a positive therapeutic response to the emergency interventions? Select all that apply. Apply the response specifically to this case: client taking antipsychotic medication who develops fever, lead-pipe rigidity, autonomic instability, and escalating confusion while staff initially attribute behavior to personality disorder.
- Client is responsive, oriented to person, place, and year, and follows commands.
- Muscles of all four extremities are pliable with minimal resistance to passive movement.
- Serum potassium is 4.1 mEq/L and serum creatinine is 1.1 mg/dL.
- Urine output is 360 mL over the last 4 hours (90 mL/hour) and is light yellow.
- Core body temperature is 37.5 C (99.5 F) and diaphoresis has resolved.
- The client refuses to discuss his psychiatric delusions with the psychiatric nurse.
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